Complaint Investigation Report

This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/7/2022.

Allegation: Staff did not follow resident's hospice care plan

It is alleged that staff do not follow resident’s hospice care plans. LPA reviewed hospice care plans for three residents. LPA spoke with facility nurse, who stated that some facility residents have hospice services and have associated care plans which are reviewed by facility staff when received and added to resident’s facility care plan, with any changes being made as indicated by hospice. LPA spoke with residents (R1-R5) regarding the allegation, of those questioned, four were unable to answer due to their medical condition and one stated they were not on hospice. Per facility files, three of them are receiving hospice services. LPA spoke with staff (S1-S6) regarding allegations. Of the staff questioned, five out of six stated facility staff follow resident’s hospice care plan. Based on information gathered, the department did not find sufficient evidence to support allegation the allegation.

Allegation: Staff performed medical procedure on resident

It is alleged that staff performed a medical procedure on a resident. LPA spoke with Nurse Chanditha Panday who stated staff do not perform medical procedures on resident, only visiting nurses perform tasks that are considered medical procedures. LPA spoke with staff (S1-S6) regarding allegations. Of the staff questioned, five out of six stated they have not performed medical procedure on residents, nor have they seen other staff perform medical procedure on residents. Based on information gathered, the department did not find sufficient evidence to support allegation the allegation.

Allegation: Staff do not provide proper medication management to residents in care

It is alleged that facility staff is making medication errors. LPA reviewed medication administration records and found no errors. LPA Cifuentes spoke with administrator David Cole regarding medication management for residents. Per administrator Cole, Facility Nurse and Medtech handle medications for residents and make sure the right medications are being given timely. He reported no complaints or issues have been reported. LPA spoke with residents (R1-R5) regarding the allegation. Of those interviewed, four were unable to answer due to their medical condition and one stated they were getting medications, they just did not know which kind. LPA spoke with staff (S1-S6) regarding allegations. Of the staff questioned, five out of six stated residents are receiving proper medication management. Based on information gathered, the department did not find sufficient evidence to support allegation the allegation.